The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BROADLAWNS MEDICAL CENTER

1801 HICKMAN ROAD DES MOINES, IA 50314

Sept. 23, 2015

VIOLATION:PATIENT RIGHTS

Tag No: A0115

I. Based on review of policies, medical record, staff interviews, the hospital failed to ensure 1 of 28 patients in the behavioral health unit received care in a safe setting and remained free from abuse following an altercation between a patient and a psychiatrist. (Patient #1 and Psychiatrist AA)

1. The hospital failed to ensure when staff placed a patient in a form of a restraint (physical hold), following an altercation with a physician, the patient remained separated, at a safe distance from the physician involved in the altercation, and remained free from abuse by the physician. (Refer to A-0144 and A-0145)

2. The hospital failed to ensure Administrative staff developed and implemented a policy to provide staff guidance and procedures to follow in the event of a witnessed or alleged abuse occurred between a patient and physician and/or staff. (Refer to A-0144)

3. The hospital failed to ensure all Behavioral Health unit psychiatrists completed the Managing Aggressive Behavior training (A crisis management program that focuses on prevention while teaching the physical and non-physical intervention skills you need to keep staff and clients safe.) upon hire in accordance with information provided by Administrative staff. (Refer to A-0144)

4. The hospital failed to ensure staff followed Mandatory Reporting procedures in accordance with the hospital ' s training provided annually to staff that included the alleged abuser remained separated from all patients during the hospital ' s investigation of a witnessed abuse incident. (Refer to A-0144 and A-0145)

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure patient care occurred in a safe setting and free from abuse.

II. During the self-reported incident investigation, the surveyor identified an Immediate Jeopardy (IJ) situation, a situation that placed the patients at risk for harm, related to Condition of Participation, Patient Rights 42 CFR 482.13.

1. The Administration staff failed to develop and implement a corrective action plan to ensure all patients would receive care in a safe setting and free from the risk of abuse following an altercation on 9/11/15 between Psychiatrist AA and Patient #1 resulting in Psychiatrist AA striking Patient #1.

2. The Administrative staff took action and put a corrective action plan in place and removed the Immediate Jeopardy prior to the exit date of the self-reported incident investigation. A condition level deficiency remained for the Condition Patient Rights.

The corrective action plan included in summary:

The Chief Medical Officer and Chief Nursing Officer reported the [Psychiatrist AA] (the alleged abuser) would not see patients and/or be physically present at Broadlawns Medical Center pending the results of the Medical Executive Committee investigation. The Medical Executive Committee would make a determination to the allegation of abuse on 9/25/15. If at that time, the Medical Executive Committee determined the allegation of abuse is founded, [Psychiatrist AA] would be terminated. If determined unfounded, precautionary restrictions would be lifted, and [Psychiatrist AA] could be recommended to return with full patient care responsibilities without conditions or with imposed additional conditions.

[Psychiatrist AA] would complete the Managing Aggressive Behavior course prior to resuming patient care responsibilities. The hospital modified the Dependent Adult, Child, and Sexual Abuse policy to include the immediate separation of staff member/physician from patient, report the incident to supervisory personnel, and complete an incident report. In addition, the policy included, the Supervisory personnel would notify Risk Management/Administration to complete the reporting requirements of the incident to the Department of Human Services, Department of Inspections and Appeals, licensing boards, and law enforcement as applicable. The evaluation would include witness interviews, and review of video recordings and completed within 3 business days following any reported allegation. The staff member/provider would be placed on administrative leave, away from the hospital, and would have no contact with patients during the investigation process.

When the allegation involved a provider and patient, the patient would be reassigned to another provider. The alleged provider (involved in the allegation) would discontinue all involvement in the patient's care, including performing assessments, writing orders, etc. The Medical Staff by-laws will be reviewed by an outside counsel that specialized in medical staff by-laws content and processes to ensure the hospital Medical Staff by-laws included the best practices of investigation processes with appropriate time frames. The Board of Trustees will approve the recommendations of the counsel.

The hospital wide Mandatory Reporting training was modified to include all policy changes. All providers and staff would be educated on policy changes. All new providers hired for the Behavioral Health unit will complete the Managing Aggressive Behavior course within 4 weeks from their hire date. The Clinical Educator will perform audits of all new providers hired for the Behavioral Health unit education records monthly for 4 months, then quarterly. The Legal Services Manager is responsible to conduct an audit of any allegation of abuse at Broadlawns Medical Center. The audit will include review of medical records, investigation notes to ensure all policies were followed to ensure separation of staff/provider from patient, to ensure the alleged provider had no involvement in the patient assessments or orders following an alleged incident, and to ensure the appropriate notifications of the alleged incident were completed. The Legal Services Manager will be responsible to report the results of the audit to the Chief Nursing Officer and the Chief Medical Officer. Administration would continue to evaluate the situation that occurred on 9/11/15 and immediately comply with all legally required reporting requirements.

VIOLATION:PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No: A0144

Based on review of polices, documents, and staff interviews, the hospital failed to ensure Administrative staff developed and implemented policies and procedures related to abuse, witnessed or alleged abuse between a patient and physician and/or staff, patient care in a safe setting, and Managing Aggressive Behavior training for psychiatric physicians.

Failure to ensure Administrative staff developed and implemented policies and procedures for abuse, witnessed or alleged abuse of a patient by the physician and/or staff, patient care in a safe setting, and Managing Aggressive Behavior training for psychiatric physicians resulted in staff failed to provide care in a safe setting for 1 of 28 Behavioral Health unit patients by staff's lack of knowledge and guidance to protect, separate, and maintain a safe distance between the patient (Patient #1) and the alleged abuser (Psychiatric Physician AA). Failure to ensure Administrative staff developed and implemented a policy to ensure 3 of 7 psychiatric physicians completed the Managing Aggressive Behavior training upon hire potentially placed all Behavioral Health unit patients at risk for harm. (Psychiatric Physicians AA, EE, and FF)

Findings include:

1. Review of hospital policy titled, "Patient Rights and Responsibilities", dated 3/2014, included in part, "...Safety...the patient has the right to receive care in safe setting... The patient has the right to be free from abuse...including physical...The medical center prohibits all forms of abuse...from staff...Abuse is defined as the willful infliction of injury, unreasonable confinement...with resulting physical harm, pain, or mental anguish...10. Behavioral Health Inpatients...In addition to above rights, patients admitted to the Behavioral Health Inpatient Unit have the right...To unimpeded, private and uncensored communication with others...with person of the patient's choice except when therapeutic or safety reasons dictate otherwise...restrictions imposed and the reasons noted will be documented in the plan of care...This standard is intended to provide protection for the patient's...safety as well as physical safety... " The policy lacked procedures and guidance for staff to follow in the event of witnessed or alleged abuse of a patient by the physician and/or staff to protect, separate, and maintain a safe distance between the patient and an alleged abuser physician and/or other staff.

2. Review of document titled, "Managing Aggressive Behavior Training Broadlawns Medical Center" included in part, "MAB (Managing Aggressive Behaviors)...is a tool that's focus is on non-physical intervention...MAB objectives...Understand how people behave in crisis...Implement prevention and early intervention strategies...Develop de-escalation and physical protection skills...Understand personal limitations and strengths...Teach patients alternative ways to deal with frustration, conflict, and anxiety...Teach patients strategies to meet their own needs and reinforce non-aggressive behaviors..." The hospital lacked a policy to provide psychiatrist guidance to teach and develop alternative ways to deal with frustration.

Review of policy titled, "Child Abuse, Newborn Safe Haven, Dependent Adult Abuse, Domestic Violence and Sexual Assault" Reviewed 05/2014 included in part, "...Broadlawns Medical Center will comply with Iowa laws on child and dependent adult abuse...All situations where child or dependent adult abuse...is suspected will be reported to the appropriate local investigative agency...All legally mandated reporters will be responsible for initialing the required verbal and written reports...Broadlawns will provide immediate protection to those...dependent adults whose physical health and emotional welfare appear to be in jeopardy...Dependent Adult...Physical Abuse...unreasonable confinement, punishment, and assault...Procedures...practitioner...has reason to believe the adult has suffered abuse, the practitioner will meet the requirements of the law by making a report...in writing...Document in the dependent adult's medical record the nature and extent of all injuries and/or reasons causing concerns to staff...All injuries, circumstances, and sources of information that pertain to...treatment...must...be carefully documented..." The policy failed to provide procedures for staff to follow in the event of a witnessed or suspected abuse between a provider/staff member and a patient.

3. During an interview on 9/17/15 at 4:10 PM, the Chief Nursing Officer, and the Legal Resources Manager reported the law enforcement or state licensing board had not been contacted regarding the altercation on 9/11/15 between [Psychiatrist AA] and [Patient #1].

a. During a follow-up interview on 9/18/15 at 8:10 AM when asked about the hospital's Child Abuse Dependent Adult Abuse Mandatory policy, Chief Nursing Officer, (CNO) stated, after three incidents last June 2014, the hospital added to their mandatory abuse curriculum as part of the Child Abuse Dependent Adult Abuse Mandatory training. The CNO stated, of what needs to happen when a staff member witnesses or suspects abuse of a patient by another staff member. The CNO stated, we also added as a part of Managing Aggressive Behaviors training (A crisis management program that focuses on prevention while teaching the physical and non-physical intervention skills you need to keep staff and clients safe.) The part about safety is the ultimate goal and the first step is to separate the aggressor and the victim. When asked for a copy of this policy, the CNO stated the mandatory abuse training curriculum is not a policy but...what staff is taught.

b. The CNO reported staff received a document titled, "Training for Mandatory Reporters of Dependent Adult Abuse" during an annual Adult Dependent Abuse Mandatory Reporter training beginning in July 2014.

c. Review of the document titled, "Training for Mandatory Reporters of Dependent Adult Abuse", Iowa Department of Human Services 2013 (curriculum added in June 2014) included in part, "...If you witness or suspect abuse you must make every effort to separate the persons to prevent further injury/abuse...If you witness abuse from a staff member, you must report immediately to your supervisor and arrange another caregiver...Reports...Who...the person suspecting the abuse...When...Immediately...notify the person in charge or designated agent...law enforcement...verbal within 24 hours...written within 48 hours...It's a crime...if you are a mandatory reporter...the abuse has occurred while you were on the job...and you knowingly and willingly failed to report it..."

d. During the interview when asked if staff notified law enforcement about the incident between [Patient #1] and [Psychiatrist AA] in accordance with the new curriculum implemented on June 2014 to the Training for Mandatory Reporters of Dependent Adult Abuse, the CNO stated, law enforcement was not notified in this case.

e. During an interview on 9/18/15 at 11:22 AM when asked if this same incident that occurred had been between a patient and a nurse, a security officer, or other staff would law enforcement of been notified. The CNO stated, not necessarily. I would talk with [Legal Resources Manager]. When asked if the CNO would report this incident to the Iowa Board of Nursing, the CNO stated, I would, if it was a nurse and if the investigation of the incident showed abuse happened.

4. During an interview on 9/16/15 at 4:40 PM, the Chief Medical Officer reported on 9/11/15 at 9:30 AM Psychiatrist AA's Section Chief told him an altercation occurred between [Patient #1] and [Psychiatrist AA]. The Chief Medical Officer reported [Patient #1] struck [Psychiatrist AA] in the face/head and it appeared that [Psychiatrist AA] struck back at the patient. The Chief Medical Officer reported after the altercation, [Psychiatrist AA] went to the walk-in clinic to be seen and the patient was taken to the patient's room. The Chief Medical Officer reported he went to the walk-in clinic and informed [Psychiatrist AA] at that time he would not see patients for the rest of the day. The Chief Medical Officer stated, I placed him on precautionary restrictions (Refer to b.) of his privileges per bylaws. The Chief Medical Officer reported on Monday 9/14/15 he called an emergent meeting and [Psychiatrist AA] was placed on precautionary restrictions until further notice from the Medical Executive Committee. The Chief Medical Officer reported [Psychiatrist AA] continued to work in his office doing administrative duties after the incident with [Patient #1].

a. The Chief Medical Officer provided a copy of an email sent to Psychiatrist AA, included in part, " ... on 9/11/15 at 3:02 PM ...I am instituting a precautionary restriction of your privileges as described under Section 12. D of the Broadlawns Medical Staff Bylaws. Effective immediately, you are restricted from seeing patients until notified differently by the Medical Executive Committee. "

b. Review of Medical Staff Bylaws, approved by the Medical Staff January 29, 2015 and approved by the Board February 17, 2015, included in part, " ...Bylaws encourage the use of progressive steps by Medical Staff Leaders...Whenever a serious question has been raised...regarding...including the...treatment...of a patient...the known or suspected violation by any member of the Medical Staff of applicable ethical standards or the Bylaws, policies, Rules or Regulations of the Medical Center or the Medical Staff...and/or conduct by any member of the Medical Staff is considered lower than the standards of the Medical Center...the matter may be referred to the President of the Medical Staff, the Department Chair, the Section Chief...12. D Precautionary Suspension of Clinical Privileges 12..1. Grounds for Precautionary Suspension...Whenever in their sole discretion, failure to take such action may result in imminent danger to the health and/or safety of any individual the Executive Committee, or the President of the Medical Staff, a Department Chair, or a Section Chief, acting in conjunction with the CMO [Chief Medical Officer], the CEO [Chief Executive Officer], or the Board Chair, shall have the authority to (1) afford an individual an opportunity to voluntarily refrain from exercising privileges pending an investigation; or (2) suspend or restrict all or any portion of an individual ' s clinical privileges as a precaution ... "

c. Review of policy titled, "Physician Code of Conduct" Revised 10/2009 included in part, "...The Broadlawns Medical Center Physicians believe in our Mission, Vision, and Values. We protect and honor this active commitment by abiding by this Code of Conduct...we individually model behavior that reflects our values. We respect the law. We are alert and report any questionable conduct...we show respect to each...patient...we shape an environment free of...criminal activity...We recognize our obligation to report...unethical...violations of the Code of Conduct...Behaviors which may be disciplined...18. Fighting or attempting bodily injury...Non-compliance of...required training...Any necessary disciplinary action will be taken only after the Medical Executive Committee makes a determination that it is appropriate to take corrective action as defined in the Medical Staff Bylaws..."

d. During a follow-up interview on 9/22/15 at 10:35 AM, the Chief Medical Officer reported after the altercation with the patient on 9/11/15, [Psychiatrist AA] worked in an office adjacent to an outpatient diagnostics clinic and patient waiting room. The Chief Medical Officer showed the route Psychiatrist AA took to work in his office. Observation showed [Psychiatrist AA] could potentially have contact with the outpatients from the diagnostics clinic and patient waiting room in the hallway outside his office.

a. During an interview on 9/18/15 at 10:35 AM Staff H, Chief Nursing Officer (CNO) provided Psychiatrist AA's official transcript document. The CNO reported [Psychiatrist AA's] file did not show he completed the Managing Aggressive Behavior training upon hire.

b. During a follow-up interview on 9/18/15 at 2:35 PM when asked for the Managing Aggressive Behavior training policy, the CNO stated, there is no policy in writing but as [Psychiatrist BB, Psychiatry Section Chief] said it was an expectation for completion upon hire.

c. During an interview on 9/22/15 at 2:35 PM when asked for documentation of Managing Aggressive Behavior for all psychiatrists, the CNO reported weekend Psychiatrists EE and FF lacked documentation of Managing Aggressive Behavior upon hire.

b. Rapid Regulatory Compliance: Clinical I, Completed on 5/1/2015 ("Rapid Regulatory Compliance Clinical I" included in part, "Welcome to the lesson on patient care and protection...Patient Assault and Abuse...To help protect patients from abuse...Manage your stress appropriately so that you so not risk taking anger and frustration out on patients...)

c. The official transcript failed to show Psychiatrist AA completed the Managing Aggressive Behavior training from Psychiatrist AA's date of hire to present date as required according to an interview on 9/17/15 at 4:55 PM with Psychiatrist AA's Psychiatry Section Chief, Psychiatrist BB.

7. Review of Psychiatrist AA's credential file revealed Psychiatrist AA with a provider employment agreement dated effective July 23, 2012 and was re-credentialed by the Medical Staff on May 12, 2015 and Board of Directors on May 19, 2015.

VIOLATION:PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No: A0145

Based on review of the medical record of an inpatient, interview with a patient and staff in the Behavior Health unit, the hospital failed to ensure 1 of 28 Behavioral Health unit inpatients involved in a witnessed altercation with a psychiatrist remained free from abuse. (Patient #1).

Failure to ensure staff protected the restrained patient and immediately separated the patient from the psychiatrist following the witnessed altercation between the patient and the psychiatrist allowed the psychiatrist to strike the patient in the head once staff had the patient physically restrained (Psychiatrist AA).

Findings include:

1. Review of Patient #1 medical record revealed the following:

a. On 9/9/15 the patient presented to the emergency department with complaints of depression and auditory hallucinations. The patient was admitted to the hospital with diagnoses of methamphetamine and marijuana use disorder, substance-induced mood disorder with psychotic features, and rule out post-traumatic stress disorder.

c. Review of Psychiatrist AA progress notes included in part, "...On 9/11/15 at 9:02 AM ...patient was seen sitting in the "lounge area" of the locked unit. Initially, the patient responded well to the MD and medical student...MD then asked the patient how he had been doing. Patient asked "what do you mean?" MD clarified that he wanted to know how the patient had been in the last day since speaking with the patient previously. Patient states he doesn't know why he is stuck in this place. When told he was court ordered to be here, he demanded to know who ordered it. His mother and brother court ordered him, but patient insists it is "impossible that his brother did that." Would not elaborate further. He continues to believe that there is no reason for him to be in "this place." He asks a couple of times when he will get to leave here... He doesn't believe he has any problems...no reason to be here. When MD states that patient has significant methamphetamine use and hears things that aren't actually happening, patient responds by saying "well yeah, I use meth (methamphetamine) every day" and then shrugged his shoulders. He minimizes his methamphetamine use as an issue. In response to the hearing voices or thinking that people are making fun of him, he still believes today that people were making fun of him yesterday. He claims people were laughing that he had dirty hands... patient continues to get more angry and aggressive. Claims he doesn't want the MD to be his psychiatrist anymore, and requests a new one. He says that the MD hasn't spent any real time talking to him. He doesn't believe that the MD "sat down with him" for long yesterday. He demands that the MD should have sat down today and shouldn't have brought a medical student. He stands up...Upon seeing the patient's increase in anger and agitation, MD proceeds as if to leave the locked unit to return later ...The patient then turned to the medical student and demanded to know what she was doing. Medical student responded by saying "I'm working with the MD" and backed away from the patient. Patient then rapidly lunged at the MD, cornered him next to a chair, and began throwing punches. MD and staff close by called the code green, (alerts other Managing Aggressive Behavior trained staff from other areas of the hospital to respond to assist with an emergency behavioral situation) and staff immediately rushed in to restrain the patient. Ativan, one (1) milligram (mg) and Haldon, five (5) mg were administered..."

d. Review of Behavioral Health Registered Nurse (RN) A's documentation included in part, "...The doctor and the patient, along with the program specialists all became trapped in the corner and the patient started...throwing punches at the doctor....Two male program specialists intercepted the patient and placed him in a physical hold...The patient was then hit in the side of the head by a staff member..."

e. Review of Psychiatric Physician Assistant (PA) GG progress notes revealed on 9/11/15 at 12:52 PM (4 hours and 22 minutes after Patient #1 was struck on the left side of the patient's head following an altercation with Patient #1 included in part, " ...This ...pt [Patient #1] was seen today for evaluation following a brief physical altercation with staff this morning. This resulted in the pt getting an IM (Intramuscular) injection ...then spending a short time in restraints. He [Patient #1] had apparently been aggressive and threatening trying to hit staff ...The pt reported that he was struck by a hand on his upper left forehead/top of head ...He states ' I ' m fine." His head does not feel sore at this time, but he does have a mild headache and he gestures to his mid forehead and over his nose. He reports that he has had a lot of headaches lately so he can not tell if it is related to the altercation. He does not feel that he needs any Tylenol or Ibuprofen. He thinks there might be a little bit of swelling on the top of his head, but none was appreciated during exam ...EXAM: head - no tenderness to palpation of forehead or top of head, no bruising or swelling noted on face, forehead, or scalp.

2. During an interview on 9/16/15 at 3:10 PM when asked what Patient #1 could remember about the incident that occurred with [Psychiatrist AA], Patient #1 stated, my recollection of the incident was after coming to...after receiving sedatives on Thursday (9/10/15) I wanted to wash my hands...my sink was broke...no one would help me. Everyone directed me back to my bathroom to wash my hands...the soap dispenser and water didn't work. Patient #1 stated, [Psychiatrist AA] comes along and takes me aside and talks with me, wants to know what...problem. I said the sink didn't work. I was frustrated. Patient #1 stated, [Psychiatrist AA] said...be giving me a room update where I can wash my hands...walked me to B unit (B hallway is a locked unit), which is a maximum security unit. Patient #1 stated, the next day, Friday (9/11/15) I met with [Psychiatrist AA]. Patient #1 stated, he came in and I was in this chair and he stood over me with two interns. When asked what [Psychiatrist AA] said Patient #1 stated, I can't remember what he said to me. I was frustrated. Patient #1 stated, I stood up and he asked me why I was so frustrated...You stood over me and tell me I was getting an upgrade and I got a downgrade. You hover (stand in one place) over me. I felt like a caged animal. You stand over me and look down on me and walk away because you are too busy to talk to me. Patient #1 stated, at that point, I pushed him (Psychiatrist AA) into a chair. Health Care Technician [HCT B and HCT C] were there and many nurses and police, security officers attacked me and held me to where I couldn't move. Patient #1 stated, I believe [Psychiatrist AA] hit me three times. I guess before security got there. [Psychiatrist AA] hit me in the left side of...head and face with his fist. I could feel his knuckles. My head was swollen for days. Patient #1 stated, I don't feel safe because they are not looking out for my best interest. I feel like a caged dog.

a. During an interview on 9/18/15 at 7:20 AM Psychiatrist BB, Psychiatry Section Chief reported on 9/11/15 she heard the code green called. Psychiatrist BB stated, [Behavioral Health unit Director] called me and told me what had happened. When asked what did the Behavioral Health unit Director tell you, Psychiatrist BB stated, a Code Green had been called, a patient in behavioral hallway had become aggressive to [Psychiatrist AA] and that [Psychiatrist AA] struck the patient. Psychiatrist BB reported she went to the unit, Patient #1 was in seclusion and medicated, and [Psychiatrist AA] was not present on the unit. Psychiatrist BB stated I called [Psychiatrist AA] and asked him to come to my office, which he did. Psychiatrist BB stated [Psychiatrist AA] told her that [Psychiatrist AA] and a medical student had been interviewing the patient in the Behavioral Health unit hallway. Patient became more agitated abruptly and it seemed the interaction with [Psychiatrist AA] was making things worse and [Psychiatrist AA] started to leave. Patient quickly stepped between medical student and door blocking her exit and the patient lunged at [Psychiatrist AA] and started hitting [Psychiatrist AA]. Psychiatrist BB stated [Psychiatrist AA] attempted to push him (Patient #1) away and the patient continued to come at him (Psychiatrist AA). Psychiatrist BB stated [Psychiatrist AA] described it as a defensive action, struck back. [Psychiatrist AA] was cornered in area and patient continued to strike at him. Staff got patient by the arms. Psychiatrist BB stated [Psychiatrist AA] described in the heat of the moment and it was not clear that patient was contained and still struggling to get at him and [Psychiatrist AA] hit Patient #1 a second time. Psychiatrist BB stated at that moment, the staff yelled that we have him. [Psychiatrist AA] said he came to his senses and backed off. Psychiatrist BB reported she contacted the Chief Medical Officer and told him about the situation.

b. During an interview on 9/17/15 at 9:35 AM, Medical Student CC stated on 9/11/15 she met with [Psychiatrist AA] and they went to see [Patient #1]. Medical Student CC stated we asked why he was in the hospital. The patient said he used meth (methamphetamine-stimulant drug) for the past two years. The medical student reported the patient told [Psychiatrist AA] he didn ' t want him to be his doctor. The medical student reported the patient said you shouldn't have been standing over me and you shouldn't have interviewed me out here with everybody else here. The medical student reported at that point, the patient stood up and she saw [Patient #1] punch [Psychiatrist AA] two times with both hands and [Psychiatrist AA's] hands came up as if to protect himself. The medical student reported staff members got the patient's hands behind the patient's back and the patient appeared to be in some sort of restraint. The medical student reported it looked like [Psychiatrist AA's] closed right hand moved forward to the patient's left posterior neck area, a shoving motion, [Psychiatrist AA's] closed hand met with the patient's body.

3. During an interview on 9/15/15 at 1:30 PM, Behavioral Health unit RN A, stated on 9/11/15 at approximately 8:30 AM she immediately went to the B hallway in the Behavioral Health unit after someone on the unit said there was a fight. RN A stated she saw several people huddled in the corner by the exit door including Health Care Technicians (HCT) B, HCT C, and HCT D standing around [Patient #1] and [Psychiatrist AA]. RN A stated [Program Specialist E] had just turned [Patient #1] around and away from [Psychiatrist AA] when she saw [Psychiatrist AA] use his left hand to reach around [HCT B], (on the patient's left side), and with his left hand strike [Patient #1] on the left side of his head. RN A stated after the incident, [Psychiatrist AA] followed the staff that were with [Patient #1] and escorted the staff and the patient to the patient's room but did not go into the patient ' s room.

During an interview on 9/15/15 at 2:40 PM when asked if Behavioral Health unit RN G was aware of the incident that occurred on 9/11/15 between [Psychiatrist AA and Patient #1] RN G reported she heard a high pitched scream and then saw a cluster of people on B hallway trying to stop [Patient #1] from punching [Psychiatrist AA]. RN G reported [Patient #1] started shouting "do it, do it, punch me again". RN G stated that's when she observed [Psychiatrist AA] use his left hand and punch the patient on the left side of his head making an audible noise. [Psychiatrist AA] used a closed fist. RN G stated [Patient #1] was controlled by staff holding the patient's arms and after the punch [Program Specialist E] came and the staff escorted [Patient #1] back to the patient's room. When asked if [Psychiatrist AA] said anything to the patient when RN G observed [Psychiatrist AA] punch the patient, RN G stated, [Psychiatrist AA] didn't say anything that I remember but he had an angry fight or flight (It is a body's automatic response that prepares the body to " fight " or " flee " from perceived attack, harm or threat to a person's survival.) look on his face when it happened.

During an interview on 9/15/15 at 4:40 PM when asked if HCT J was aware of the incident that occurred on 9/11/15 between [Psychiatrist AA] and [Patient #1] HCT J reported he heard someone say "Oh no" and then he went to B hallway. HCT J stated, [HCT D] was on [Patient 1's] left hand side and had a hold of [Patient #1's] left arm. Either [HCT F] or [HCT B] was on the patient's right side holding [Patient 1's] right arm. At that time [Patient 1] was motionless and slightly bent over at...waist with arms straight out and knees slightly bent.

During an interview on 9/15/15 at 4:55 PM when asked if HCT D observed the incident that occurred on 9/11/15 between [Psychiatrist AA] and [Patient #1] HCT D stated on 9/11/15 at around 8:30 AM Patient #1 was sitting in the television area on B hallway and [Psychiatrist AA] was standing talking to [Patient #1]. HCT D stated [Patient #1] verbalized issues...he was not able to go home and that he wanted one to one conversation with [Psychiatrist AA] and he was bothered because everyone was listening to his issues. HCT D reported the patient was telling [Psychiatrist AA] when the patient was hospitalized at a different hospital he had one on one sessions with the psychologist. HCT D stated [Patient #1] was not happy with [Psychiatrist AA's] approach to the patient. HCT D stated the patient suddenly got agitated and [Psychiatrist AA] sensed something was going to happen and [Psychiatrist AA] started to leave. HCT D stated [Patient #1] said, "Oh so you want to leave". That was when the patient suddenly stood up and without any warning hit [Psychiatrist AA]. When asked if HCT D had seen [Patient #1] hit [Psychiatrist AA] HCT D said he could not see if patient hit [Psychiatrist AA] but could see patient's arms moving up and like patient was hitting [Psychiatrist AA]. HCT D stated he helped HCT B to manhandle (handle someone roughly) Patient #1 by grabbing the patient's arms. HCT D stated he and HCT B got a hold of Patient #1 and turned the patient so the patient's back was toward [Psychiatrist AA]. HCT D said at that moment the patient said, "Okay - okay". The patient didn't resist at that time once we grabbed the patient. HCT D said [Psychiatrist AA] kept asking HCT B and me to get him down...asked us twice to get him down. I said, "We got him, we got him". Then I heard a smack...impact against the patient's head. Sounded like...I can't distinguish the sound. When asked if HCT D observed [Psychiatrist AA] strike [Patient #1] HCT D stated, I didn't see anything because I was forward on my hold on the patient. HCT D stated, "The patient said oh you hit me or something to that effect."

During an interview on 9/16/15 at 7:45 AM when asked where HCT F was on 9/11/15 when the incident occurred between [Psychiatrist AA] and [Patient #1]. HCT F stated he was in the common area (television room) with [HCT B, HCT C, HCT D, Patient #1], [Psychiatrist AA], and maybe two other patients. HCT F said [Patient #1] was saying to [Psychiatrist AA], "Why don't you sit down", and [Psychiatrist AA] said he was going to leave. {Patient #1] said, "What, you aren't going to give me an hour like other doctors would"? [Psychiatrist AA] responded, "No I can't do that today I have several other patients to see and I don't have time to do that unfortunately." HCT F reported [Psychiatrist AA] started to open the door and [Patient #1] went up behind [Psychiatrist AA] and struck him in the back of his head. HCT F reported the four [HCT's] ran and got a hold of the patient's arms. HCT F said we pulled the patient back about three steps to separate...from [Psychiatrist AA] and then patient was restrained and then out of nowhere...[Psychiatrist AA] took about one step forward and swung at [Patient #1] striking patient on right side of head. HCT F stated, "It appeared to me [Psychiatrist AA] used the closed fist of his right hand to strike the patient". HCT F said when [Psychiatrist AA's] blow struck [Patient #1's] head, there was a loud pop sound. When asked what the patient said after [Psychiatrist AA] struck him in the head, HCT F stated, [Patient #1] yelled at [Psychiatrist AA]...accused him of giving him a cheap shot (an unfair or malicious attack on someone/somebody). HCT F saideverything happened so fast. The nurses came through the doorway into the hallway with a safety officer because we had called a code green.

During an interview on 9/16/15 at 8:35 AM when asked if HCT C observed the incident that occurred on 9/11/15 between [Psychiatrist AA] and [Patient #1], HCT C reported the patient was getting agitated. The patient told [Psychiatrist AA] he was not here for mental health, he had an addiction and that he wanted help. HCT C stated [Psychiatrist AA] said he was [Patient #1's] physician while he was here and he would get him help which agitated [Patient #1]. HCT C said the patient mentioned to the physician he didn't get an hour and asked the physician, "Don't you sit down and talk to me". [Psychiatrist AA] tried to explain our setting (the Behavioral Health unit) and that it wasn't like a therapy session with his therapist. HCT C stated Patient #1 was agitated and said something like you wouldn't be like this professionally, standing above me, looking down on me, and in front of all these people. HCT C reported there were other staff and patients in the area and a medical student observing [Psychiatrist AA]. HCT C reported at this point [Patient #1] stood up. HCT C reported she saw [Patient #1] lunge at [Psychiatrist AA]. HCT C stated Patient #1 swung at [Psychiatrist AA] with his right closed fist. She was unaware if [Patient #1's] swing hit [Psychiatrist AA]. HCT C reported either HCT B or HCT D went to [Patient #1] and grabbed Patient #1's arm. HCT C stated she and other staff grabbed Patient #1's arms and moved him back and turned him so [Patient #1] was facing away from the physician. HCT C stated she pushed her code green button. HCT C stated somebody said, "Let's get him down", meaning to take the patient to his knees and safely to the floor to further restrain the patient. HCT C stated the patient was still standing and that was when [Psychiatrist AA] crossed over top of everyone with his closed fist and struck [Patient #1] in the head. HCT C reported she saw [Psychiatrist AA's] closed fist strike [Patient #1] in the left side of the patient's head. When asked if [Psychiatrist AA] said anything to [Patient #1] during the altercation, HCT C said [Psychiatrist AA] didn't say anything but the look on his face was a very vindictive (to seek revenge) look, very angered look.

During an interview on 9/16/15 at 10:30 AM HCT B stated [Psychiatrist AA] and his medical student entered B hallway and approached [Patient #1] and throughout the interview Patient #1 was getting more agitated. [Patient #1] was upset about the court order. HCT B said at one point [Patient #1] said why are you talking to me out here and not in my room privately. Why are you standing over me? HCT B stated at that point [Patient #1] stood up and told [Psychiatrist AA] he "didn't want him to be his doctor anymore, he wanted someone to talk to him longer than three minutes." HCT B reported [Patient #1] stood up and lunged at [Psychiatrist AA] and [Patient #1] started swinging with closed fists towards [Psychiatrist AA]. HCT B said he held [Patient #1's] left arm and Staff D held [Patient #1's] right arm. HCT B aid at that point he could not feel [Patient #1] resisting or fighting us off. HCT B stated [Psychiatrist AA] punched Patient #1's left temple side of his head with a closed fist. HCT B stated when [Psychiatrist AA] made contact with [Patient #1's] head there was an audible thump. When asked if [Psychiatrist AA] said anything after he struck [Patient #1] HCT B stated, [Psychiatrist AA] didn't say anything after the hit. [Patient #1] said something like, "Oh now you are going to hit me". HCT B reported the staff then walked Patient #1 to his room.